Docs Say Payers Restored Prior Authorization in COVID Second Wave

As new cases of COVID-19 peaked in late 2020, most physicians reported that payers had either reinstated prior authorization policies or never relaxed policies to begin with, based on an American Medical Association survey of 1,000 practicing physicians.

Some commercial health plans temporarily relaxed prior authorization requirements at the onset of the pandemic to remove administrative burdens and support timely care access. However, the AMA survey found that most physicians faced strict authorization hurdles by December 2020 when new COVID-19 cases per week reached record numbers.

Nearly 70 percent of respondents reported that health payers had either reinstated prior authorization policies or never relaxed policies to begin with, and 94 percent reported care delays while waiting for health plan authorization.

These delays have serious consequences for patient adherence to care plans, with almost 80 percent of physicians noting that patients abandon treatment due to authorization struggles with payers. What’s more, nine in 10 physicians reported that prior authorization programs have a negative impact on patient clinical outcomes.

“Delayed and disrupted treatment due to an archaic prior authorization process can have life-or-death consequences for patients, especially during a public health emergency,” AMA President Susan R. Bailey, MD said in a press release. “This hard-learned lesson from the current crisis must guide a reexamination of administrative burdens imposed by health insurers, often without any justification.”

According to the survey, 30 percent of physicians reported that prior authorization barriers led to serious adverse events for patients in their care. More specifically:

• 21 percent of respondents said that prior authorization requirements led to patient hospitalization.
• Almost 20 percent of respondents said that the requirements led to life-threatening events or interventions to prevent permanent impairment for patients.
• Nine percent of physicians reported that care delays due to prior authorization led to patient disability, congenital anomaly, permanent bodily damage, birth defect, or death.

In addition to constraining access to care, 85 percent of physicians reported that the administrative burdens from prior authorization were high or extremely high.

Additionally, while payers note that prior authorization policies reflect evidence-based medicine, 15 percent of physicians reported that these policies were often or always based on evidence-based medicine.

The survey results revealed that medical practices complete an average of 40 prior authorizations per physician, per week. This equates to two business days (16 hours) of physician and staff time, a significant administrative burden that results in 40 percent of physicians employing staff members to work exclusively on prior authorization tasks.

Therefore, the AMA noted that prior-authorization reform may not only lead to better patient outcomes by minimizing care delivery delays, but it may also lower healthcare expenditures through streamlining or eliminating the administrative burden of prior authorization.

In January 2018, the AMA and other national organizations representing health plans, pharmacists, medical groups, and hospitals signed a consensus statement underscoring a commitment to improving five crucial aspects of the prior authorization process. However, according to the AMA, health plans have made minimal progress over the last three years toward making improvements in each of the five areas highlighted in the consensus statement.

Most (98 percent) commercial health plans argue that the prior authorization practices improve care quality and support evidence-based care, according to an AHIP survey published last June.

The survey also found that payers use prior authorization policies to ensure patient safety (91 percent) and to provide intervention in areas that were vulnerable to substance abuse (84 percent). Almost eight in ten plans (79 percent) used prior authorizations to lower healthcare expenditures.

Over 90 percent of the payer respondents reported a positive impact on quality of care and affordability, and more than 80 percent of participants said that they saw a positive impact on safety.

Electronic prior authorization technology could lead to a more streamlined authorization process, according to a study conducted on behalf of AHIP. Over seven in ten physicians who used electronic prior authorization reported that the tool sped up the time it took for them to deliver care to the patient, and more than half of the respondents reported fewer phone calls and fewer faxes related to prior authorization.